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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:29:42 PM

Document Has Been Signed on 10/16/2024 02:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR/
DIRECTOR:		JOSEPHINE B. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Annabelle Dorado (staff)TIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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On 10/16/2024 at 11:50 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required – Annual Continuation Inspection. LPA was greeted and granted access by staff Annabelle Dorado. A second staff Sandra Higareda greeted LPA. LPA requested staff contact the administrator, Josephine Miranda and inform them LPA was at the facility. According to staff Josephine was unavailable due to a scheduled appointment. Staff informed LPA they sent Josephine a message but had not heard back. At 12:44 p.m. LPA contacted Administrator's cell phone number and left a voicemail. LPA then contacted Jackylyn Miranda who had their administrator certificate and telephone number displayed in the facility but nobody answered. LPA continued visit with staff. Four (4) residents and two (2) staff were present during this inspection.

LPA conducted a physical plant tour of the facility inside and out.

The following was attempted to complete the annual inspection:


LPA attempted to review facility, staff and resident records. Staff informed LPA they did not have access to records to present to LPA. LPA had not received a copy of the facility's Infection Control Plan, LPA requested on 05/13/2024. Administrator had still not made themselves available by 2:10 p.m.

Staff agreed to sign todays report.

Deficiencies cited (refer to LIC809-D). Exit Interview Conducted. Appeal Rights provided. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/16/2024 02:29 PM - It Cannot Be Edited


Created By: Evelin Rios On 10/16/2024 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.
FACILITY NUMBER: 197607012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not providing the department notice of a designated manager when they were not aviable which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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LIcensee will provide LPA the LIC308 and a statement of understanding for the cited regulation by POC due date 10/31/2024.
Type B
Section Cited
CCR
87755(c)
(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based interview and record review, the licensee did not comply with the section cited above in not making themselves available to provide records upon request which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee will contact LPA once they are available (M-F 8 a.m. to 5:00 p.m.). Licensee will provide a statement of understanding on the cited regulation to LPA by POC due date 10/31/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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